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Psychological Services Bringing Chronic-Pain Care to Rural Veterans: A Telehealth Pilot Program Description Lisa H. Glynn, Jessica A. Chen, Timothy C. Dawson, Hannah Gelman, and Steven B. Zeliadt Online First Publication, January 16, 2020. http://dx.doi.org/10.1037/ser0000408

CITATION Glynn, L. H., Chen, J. A., Dawson, T. C., Gelman, H., & Zeliadt, S. B. (2020, January 16). Bringing Chronic-Pain Care to Rural Veterans: A Telehealth Pilot Program Description. Psychological Services. Advance online publication. http://dx.doi.org/10.1037/ser0000408

Bringing Chronic-Pain Care to Rural Veterans: A Telehealth Pilot Program Description

Lisa H. Glynn Veterans Affairs Puget Sound Health Care System,

Seattle, Washington

Jessica A. Chen and Timothy C. Dawson Veterans Affairs Puget Sound Health Care System, Seattle,

Washington, and University of Washington

Hannah Gelman Denver–Seattle Center of Innovation (COIN) for Veteran-

Centered Value-Driven Care, Seattle, Washington

Steven B. Zeliadt Denver–Seattle Center of Innovation (COIN) for Veteran-

Centered Value-Driven Care, Seattle, Washington, and University of Washington

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic- pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive–behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encoun- ters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion.

Impact Statement A pilot project was created to bring chronic-pain care by telehealth to rural patients at Veterans Affairs (VA) clinics in their local communities. The program increased access to safer alternatives to opioid medications, including pain education and psychotherapy. New funding will expand the program to the rest of VA’s Northwest Region.

Keywords: chronic pain, opioid safety, rural health, telehealth, veterans

People with chronic pain who reside rurally are at elevated risk of negative outcomes. Rural areas of the United States have been affected disproportionately by the opioid public-health crisis, as evidenced by higher rates of opioid prescribing, opioid misuse,

substance use disorders, and unintentional overdose (e.g., Dowell, Haegerich, & Chou, 2019; Lund, Ohl, Hadlandsmyth, & Mosher, 2019; O’Brien, 2015; Palombi, St. Hill, Lipsky, Swanoski, & Lutfiyya, 2018). The co-occurrence of chronic pain and opioid use

X Lisa H. Glynn, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; X Jessica A. Chen, Denver–Seattle Center of Inno- vation (COIN) for Veteran-Centered Value-Driven Care, VA Health Ser- vices Research & Development (HSR&D) and Veterans Affairs Puget Sound Health Care System, and Department of Psychiatry & Behavioral Sciences, University of Washington; X Timothy C. Dawson, Veterans Affairs Puget Sound Health Care System, and Department of Anesthesi- ology, University of Washington; X Hannah Gelman, Denver–Seattle Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, VA Health Services Research & Development (HSR&D), Seattle, Wash- ington; Steven B. Zeliadt, Denver–Seattle Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, VA Health Services Research &

Development (HSR&D), and Department of Health Services, University of Washington.

The Pain Telehealth pilot was a quality-improvement project of VA Puget Sound. The authors thank their collaborators at Veterans Integrated Service Network 20, Bradford Felker and the Promoting Access through Telemental Health and Western Telehealth Network teams, the VA Puget Sound Telehealth Committee, and Eva Thomas and Chelle Wheat for their assistance in data preparation. The views expressed in this article are those of the authors, and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Correspondence concerning this article should be addressed to Lisa H. Glynn, Veterans Affairs Puget Sound Health Care System, 1660 South Co- lumbian Way (S-112 ANES), Seattle, WA 98108. E-mail: lisa.glynn2@va.gov

Psychological Services In the public domain 2020, Vol. 1, No. 999, 000 ISSN: 1541-1559 http://dx.doi.org/10.1037/ser0000408

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disorder is associated with increased suicide risk and the co- occurrence of other psychiatric diagnoses (e.g., mood, anxiety, trauma-related, substance-use, or personality disorders), which can complicate effective care for these patients (Barry et al., 2016; Bernardy & Montaño, 2019; Dowell et al., 2019; Oliva et al., 2017).

Problem Description and Available Knowledge

Opioid medications are not only risky, but also do not clearly improve chronic-pain outcomes or confer functional benefits over less risky pain medications (e.g., Chou et al., 2015; Krebs et al., 2018). Research-based clinical-practice guidelines (Department of Veterans Affairs & Department of Defense, 2017; Dowell, Hae- gerich, & Chou, 2016) generally discourage long-term opioids for chronic pain, and instead support the delivery of biopsychosocial alternatives as first-line treatments for chronic pain, including pain education, cognitive–behavioral therapy, physical therapy and paced-exercise treatments, and self-management. Biopsychosocial modalities are effective for improving functional status (Becker et al., 2018; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). They may be enhanced when combined through a comprehensive interdisci- plinary approach, which may also include nonopioid medications and complementary and integrative medicine (Department of Vet- erans Affairs & Department of Defense, 2017; Gatchel, McGeary, McGeary, & Lippe, 2014). Evidence-based psychotherapies— such as Cognitive–Behavioral Therapy for Chronic Pain (Ehde, Dillworth, & Turner, 2014; Murphy et al., 2014), Acceptance and Commitment Therapy for Chronic Pain (e.g., Veehof, Trompetter, Bohlmeijer, & Schreurs, 2016), Motivational Inter- viewing (e.g., Alperstein & Sharpe, 2016), and mindfulness or mind– body interventions (Garland et al., 2019; Maglione et al., 2016)—are safe and potent elements of comprehensive chronic- pain care that can be viable alternatives to opioids (Majeed, Ali, & Sudak, 2019).

However, effective treatment modalities for chronic pain and co-occurring conditions are not always accessible to patients who are likely to benefit from them. Comprehensive chronic-pain ser- vices are not covered by all health care systems and insurance plans (Keogh, Rosser, & Eccleston, 2010), and rural patients are more likely to be uninsured (Centers for Disease Control, 2018). The availability of interdisciplinary chronic-pain teams in the United States has decreased sharply in recent years (Schatman, 2018), and this problem is compounded in rural areas, where few specialty pain providers practice (Arout, Sofuoglu, & Rosenheck, 2017; Breuer, Pappagallo, Tai, & Portenoy, 2007; Department of Health and Human Services, National Center for Health Work- force Analysis, 2014; Eaton et al., 2018). In addition, geographical inaccessibility can exacerbate other barriers to care, such as limited mobility, lack of transportation, financial difficulties, and co- occurring medical or psychiatric concerns (Department of Veter- ans Affairs, Office of Rural Health, 2019; Rural Health Informa- tion Hub, 2016). Patients with chronic pain who reside rurally are thus high in need, but subject to significant disparities. Telehealth has been proposed as one solution to more equitably distribute specialty pain resources that tend to be concentrated at large urban medical centers.

Rationale for Telehealth